Emergency Severity Index (ESI) algorithm in trauma patients: The impact of age during the pandemic.

OBJECTIVE: The ESI algorithm is widely used to triage patients in the emergency room. However, few studies have assessed the reliability of ESI to accurately triage trauma patients. The aim of this study was to compare vital signs, resource utilization, and patient outcomes among trauma patients during the pandemic in 2020 vs. the previous year prior to the pandemic. METHODS: This retrospective study was conducted over a 24-month period at an urban adult level one trauma center. Demographic and clinical characteristics, resource utilization, and patient outcomes were extracted from the electronic medical records and trauma registry. Trauma patients assigned ESI level 2 were stratified by age (<65 years and ≥ 65 years) and year (2019 vs. 2020) for data analysis. RESULTS: A total of 3,788 trauma patients were included in the study. Males represented 68.4% (2,591) of patients and the median age was 50 years (IQR: 31, 69). The majority of patients were assigned ESI level 2 (2,162, 57.1%) and had a blunt mechanism of injury (3,122, 82.4%). In 2020, patients <65 years of age utilized less resources compared to 2019 (p < 0.001). Likewise, patients >65 years of age required less lab tests [OR: 0.1, 95% CI: (0.05 - 0.4)], IV fluids [OR: 0.2, 95% CI: (0.2 -0.3)], IV medications [OR: 0.6, 95% CI: (0.4 - 0.7)], and specialty consultations [OR: 0.4, 95% CI: (0.3 -0.5)] compared to 2019 (p < 0.0001). Within 2020, vital signs and resources utilized between younger and elderly patients varied significantly (p < 0.01). Correspondingly, the clinical outcomes between younger and elderly patients within 2020, differed significantly (p < 0.01). CONCLUSIONS: The COVID-19 pandemic affected the triage of trauma patients. During 2020, patients utilized less resources compared to the previous year. Additionally, younger and elderly patients had different vital signs, resource utilization, and clinical outcomes although both being assigned ESI level 2. Younger trauma patients may have been over-triaged in 2020 due to the COVID-19 pandemic.

Development of cool and hot executive function deficit in children born very low birth weight with normal early development: A longitudinal cohort from aged 6 to 10.

BACKGROUND: Studies showed preterm children born with very low birth weight (VLBW, <1500 g) are at risk for poorer executive functions (EFs). However, very little research has been reported longitudinally on the development of both cool and hot EFs deficits in preschool to school-age VLBW preterm children with normal early development. AIMS: Present study aimed to investigate the development of cool and hot EFs in VLWB preterm children longitudinally. METHODS: Forty preterm children born VLBW were followed up at ages 6, 8, and 10. Fifty term-born controls were recruited at each age stage. Cool EFs was assessed using backward digit span subtest of WISC-IV, Knox's Cube Test, Comprehensive Non-verbal Attention Test Battery (CNAT), Tower of London (ToL), Wisconsin Card Sorting Test (WCST), and hot EFs was assessed using Theory of Mind (ToM) and Delay of Gratification (GIFT) tasks. RESULTS: The six-year-old VLBW preterm group showed significantly lower scores of planning in ToL, inhibition control in CNAT, and in both ToM and GIFT tasks. There is no significant difference in average cool and hot EFs between the eight and ten-year-old preterm group and the control group. CONCLUSIONS: At six, VLBW preterm infants with normal early development have delayed cool and hot EFs development. Although the average performance of EFs can reach the level of the control group with age increasing to eight and ten years, there are still individual differences. It is recommended that more complete development indicators be established in the future, and early intervention should be made for VLBW premature children with delayed EFs.

Detection of COVID-19 using multimodal data from a wearable device: results from the first TemPredict Study.

Early detection of diseases such as COVID-19 could be a critical tool in reducing disease transmission by helping individuals recognize when they should self-isolate, seek testing, and obtain early medical intervention. Consumer wearable devices that continuously measure physiological metrics hold promise as tools for early illness detection. We gathered daily questionnaire data and physiological data using a consumer wearable (Oura Ring) from 63,153 participants, of whom 704 self-reported possible COVID-19 disease. We selected 73 of these 704 participants with reliable confirmation of COVID-19 by PCR testing and high-quality physiological data for algorithm training to identify onset of COVID-19 using machine learning classification. The algorithm identified COVID-19 an average of 2.75 days before participants sought diagnostic testing with a sensitivity of 82% and specificity of 63%. The receiving operating characteristic (ROC) area under the curve (AUC) was 0.819 (95% CI [0.809, 0.830]). Including continuous temperature yielded an AUC 4.9% higher than without this feature. For further validation, we obtained SARS CoV-2 antibody in a subset of participants and identified 10 additional participants who self-reported COVID-19 disease with antibody confirmation. The algorithm had an overall ROC AUC of 0.819 (95% CI [0.809, 0.830]), with a sensitivity of 90% and specificity of 80% in these additional participants. Finally, we observed substantial variation in accuracy based on age and biological sex. Findings highlight the importance of including temperature assessment, using continuous physiological features for alignment, and including diverse populations in algorithm development to optimize accuracy in COVID-19 detection from wearables.

Demographic and Socioeconomic Characteristics of COVID-19 Patients Treated in the Emergency Department of a New York City Hospital.

Demographic and socioeconomic factors can contribute to community spread of COVID-19. The aim of this study is to describe the demographics and socioeconomic factors in relation to geolocation of COVID-19 patients who were discharged from the emergency department (ED) back into the community. This retrospective study was conducted over a 7-week period, at an urban, adult, level 1 trauma center in New York City. Demographics, socioeconomic factors, and geolocation of COVID-19 patients discharged from the ED were extracted from the electronic medical records. Patients were stratified by gender for data analysis. A total of 634 patients were included in the study, 376 (59.3%) were male and 205 (32.3%) were Hispanic White. The median age of patients was 50 years (IQR: 38, 60, Min:15, Max:96). The unemployment rate in our population was 41.2% and 75.5% reported contracting the virus via community spread. ED mortality rate was 11.8%; the majority of which were male (N = 50, 66.7%) and the median age was 70 years (IQR: 59, 82). There were 9.4% (95% CI 2.9-12.4) more Black males and 5.4% (95% CI 0.4-10.4) more males who had no insurance coverage compared to females. 26.8% (95% CI 14.5-39) more females worked in the healthcare field and 7.1% (95% CI 0.3-13.9) more were infected via primary contact compared to males. COVID-19 disproportionately affected minorities and males. Socioeconomic factors should be taken into consideration when preparing strategies for preventing the spread of the virus, especially for individuals who are expected to self-isolate.

Accuracy of pre-hospital trauma notification calls.

STUDY OBJECTIVE: The aim of this study is to determine the accuracy of pre-hospital trauma notifications and the effects of inaccurate information on trauma triage. METHODS: This study was conducted at a level-1 trauma center over a two-year period. Data was collected from pre-notification forms on trauma activations that arrived to the emergency department via ambulance. Trauma activations with pre-notification were compared to those without notification and pre-notification forms were assessed for accuracy and completeness. RESULTS: A total of 2186 trauma activations were included in the study, 1572 (71.9%) had pre-notifications, 614 (28.1%) did not and were initially under-triaged. Pre-notification forms were completed for 1505 (95.7%) patients, of which EMS provided incomplete/inaccurate information for 1204 (80%) patients and complete/accurate information for 301 (20%) patients. Missing GCS/AVPU score (1099, 91.3%), wrong age (357, 29.6%), and missing vitals (303, 25.2%) were the main problems. Missing/wrong information resulted in trauma tier over-activation in 25 (2.1%) patients and under-activation in 20 (1.7%) patients. Under-triaged patients were predominantly male (18, 90%), sustained a fall (9, 45%), transported by BLS EMS teams (12, 60%), and arrived on a weekday (13, 65%) during the time period of 11 pm-7 am (9, 45%). A total of 13 (65%) required emergent intubation, 2 (10%) required massive transfusion activation, 7 (35%) were admitted to ICU, 3 (15%) were admitted directly to the OR, and 1 (15%) died. CONCLUSION: EMS crews frequently provide inaccurate pre-hospital information or do not provide any pre-hospital notification at all, which results in over/under triage of trauma patients.

Variability in CT imaging of blunt trauma among ED physicians, surgical residents, and trauma surgeons.

BACKGROUND: Trauma triage decisions can be influenced by both knowledge and experience. Consequently, there may be substantial variability in computed tomography (CT) scans desired by emergency medicine physicians, surgical chief residents, and attending trauma surgeons. We quantified this difference and studied the effects of each group's decisions on missed injuries, cost, and radiation exposure. METHODS: All blunt trauma activations at an urban level 1 trauma center were studied over a 6-mo period. Three months into the study, a pan-scan protocol was introduced. Prior to CT imaging, providers separately completed a survey that asked which CT scans were desired for each patient. Based on the completed surveys, hypothetical missed injuries, radiation exposure, and cost were determined. RESULTS: The variability in the number of CT scans desired by each of the three providers and the resulting cost and radiation exposure were not statistically significant. Substantial variability was predominantly seen in the indications for the desired scans, with the difference between proportions ranging from 3.1%-68.7%. Agreement among the three providers was highest for head and c-spine scans (80%-100%) and lowest for maxillary face (57%-80%) and chest scans (52%-74%). Overall, the missed injury rate was similar for all the providers; chief residents missed significantly more major injuries than trauma attendings during the pan-scan period (P = 0.03). CONCLUSIONS: Trauma training and level of training did not have a substantial effect on radiological decisions during the initial trauma assessment. This study sheds light on the growing uniformity among providers with regard to medical decision-making in the initial work-up of trauma.

Incidental findings in blunt trauma patients: prevalence, follow-up documentation, and risk factors.

PURPOSE: The frequency of computed tomography (CT) imaging of trauma patients has given rise to an increase in the discovery of incidental findings. The purpose of this study was to evaluate the frequency and documentation of follow-up recommendations of incidental findings during the initial trauma evaluation. Secondarily, trauma patients with and without incidental findings were compared. We hypothesized that there would be a high rate of incidental findings in trauma patients and that these findings would be poorly documented. METHODS: A retrospective review of CT imaging performed during trauma assessment at an urban level 1 trauma center was conducted. Prospectively documented incidental findings over a 6-month period were recorded. The frequency of incidental findings and follow-up referrals were analyzed. Mann-Whitney non-parametric test and Fisher's exact test were used to compare patients with and without incidental findings, and logistic regression was performed to identify independent risk factors. RESULTS: Of the 1573 CT scans performed, 478 (30.4%) revealed incidental findings. The abdomen/pelvis had the highest rate of incidental findings (61.7%). Of the 416 patients, 295 (70.9%) had a total of 858 incidental findings, with an average of 3 findings per patient. Follow-up was required for 24 (2.8%) incidental findings, and admission/immediate intervention was required for 6 (0.7%) findings. Only 12 (1.4%) incidental findings were documented in the discharge note. Increasing age (p < 0.001), a higher body mass index (BMI) (p = 0.015), and receiving a pan-CT (p < 0.001) increased the odds of having an incidental finding. CONCLUSION: A large percentage of trauma patients have incidental findings. Therefore, better documentation and follow-up are needed to determine the long-term outcomes of patients with clinically relevant incidental findings.

Introduction of a pan-scan protocol for blunt trauma activations: what are the consequences?

STUDY OBJECTIVE: The aim of this study is to determine if the introduction of a pan-scan protocol during the initial assessment for blunt trauma activations would affect missed injuries, incidental findings, treatment times, radiation exposure, and cost. METHODS: A 6-month prospective study was performed on patients with blunt trauma at a level 1 trauma center. During the last 3 months of the study, a pan-scan protocol was introduced to the trauma assessment. Categorical data were analyzed by Fisher exact test and continuous data were analyzed by Mann-Whitney nonparametric test. RESULTS: There were a total of 220 patients in the pre-pan-scan period and 206 patients during the pan-scan period. There was no significant difference in injury severity or mortality between the groups. Introduction of the pan-scan protocol substantially reduced the incidence of missed injuries from 3.2% to 0.5%, the length of stay in the emergency department by 68.2 minutes (95% confidence interval [CI], -134.4 to -2.1), and the mean time to the first operating room visit by 1465 minutes (95% CI, -2519 to -411). In contrast, fixed computed tomographic scan cost increased by $48.1 (95% CI, 32-64.1) per patient; however, total radiology cost per patient decreased by $50 (95% CI, -271.1 to 171.4). In addition, the rate of incidental findings increased by 14.4% and the average radiation exposure per patient was 8.2 mSv (95% CI, 5.0-11.3) greater during the pan-scan period. CONCLUSION: Although there are advantages to whole-body computed tomography, elucidation of the appropriate blunt trauma patient population is warranted when implementing a pan-scan protocol.